HIV MONITORING QUARTERLY REPORT

HIV MONITORING QUARTERLY REPORT FOR VANCOUVER COASTAL HEALTH FOURTH QUARTER 2013 the northern way of caring

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Foreword As part of the BC Centre for Excellence (BC-CfE) in HIV/AIDS s mandate to evaluate the outcomes of STOP HIV/AIDS programming in BC, we have developed quarterly HIV/AIDS monitoring reports. These reports provide up-to-date data on a variety of key HIV-related surveillance and treatment indicators. Selection of these indicators was achieved through a collaborative process with various Health Authority (HA) representatives. There are six reports in total, one for each HA and one for the province of BC as a whole. In addition, there is a technical report which explains how each HIV indicator is calculated. Data used in these reports come from the British Columbia Centre for Disease Control (BCCDC), MSP billings, hospitalization data from the Discharge Abstract Database, the Sunquest Laboratory database at the Provincial Public Health Microbiology and Reference Laboratory, Providence Health Care laboratory and the BC-CfE Drug Treatment Program (DTP) Database. The objectives of these reports are to: 1. Provide timely HA-specific information on key HIV indicators which will guide and inform HIV leaders and innovators in the development of future HIV interventions and programs which will ultimately lead to decreasing the burden of HIV in BC. The indicators will reflect ongoing or past successful public health interventions and highlight areas in the HIV care spectrum which require further attention and support. 2. Highlight limitations in our current data due to incomplete or time lagged data and to develop future strategies to improve complete and timely data capture. These reports are produced for the benefit of individual HAs. As such, we are enthusiastic about your involvement and cooperation regarding the development of these monitoring reports. Please forward your comments and queries to Irene Day, Director of Operations at the BC-CFE at iday@cfenet.ubc.ca. 3

List of Indicators Indicator 1. Testing Episodes Indicator 2. HIV Testing Rate Indicator 3. New HIV Diagnoses Indicator 4. Stage of HIV Infection at Diagnosis Indicator 5. HIV Cascade of Care Indicator 6. Programmatic Compliance Score (PCS) Indicator 7. New Antiretroviral Starts Indicator 8. CD4 Cell Count at ART Initiation Indicator 9. Active and Inactive Drug Treatment Program Participants Indicator 10. Antiretroviral Adherence Level Indicator 11. Resistance Testing Results by Resistance Category Indicator 12. AIDS-Defining Illness Indicator 13. HIV-Related Mortality 4

Table of Contents Acknowledgements and Contributions BC Provincial STOP Program: A Note on Monitoring and Interpreting HIV Indicators Indicator 1 Figure 1.1 Figure 1.2 Figure 1.3 Figure 1.4 Figure 1.5 Indicator 2 HIV Testing Episodes HIV Test Episodes for Vancouver Coastal Health, 2009 Q1 2013 Q4 HIV Test Episodes for Vancouver Coastal Health by Gender and Prenatal Status, 2009 Q1 2013 Q4 HIV Test Episodes for Vancouver Coastal Health by Age Category, 2009 Q1 2013 Q4 Point-of-Care HIV Tests for Vancouver Coastal Health, 2010 Q4 2013 Q4 HIV Test Episodes by HSDA for Vancouver Coastal Health, 2009 Q1 2013 Q4 HIV Testing Rates Figure 2.1 Rate of HIV Testing for Vancouver Coastal Health and HSDA s, 2009 2013 Figure 2.2 Rate of HIV Testing for Vancouver Coastal Health by Gender, 2009 2013 Figure 2.3 Rate of HIV Testing for Vancouver Coastal Health by Age Category, 2009 2013 Indicator 3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Indicator 4 Table 1 New HIV Diagnoses New HIV Diagnoses for Vancouver Coastal Health, 2009 Q1 2013 Q4 New HIV Diagnoses for Vancouver Coastal Health by Gender, 2009 Q1 2013 Q4 New HIV Diagnoses for Vancouver Coastal Health by Age Category, 2009 Q1 2013 Q4 New HIV Diagnoses for Vancouver Coastal Health by Exposure Category, 2009 Q1 2012 Q2 New HIV Diagnoses for Vancouver Coastal Health by HSDA, 2009 Q1 2012 Q4 Stage of HIV Infection at Diagnosis Staging Classifications of Infection at Time of HIV Diagnosis Based on CDC HIV Surveillance Case Definitions Figure 4.1 Stage of HIV Infection at Diagnosis for Vancouver Coastal Health, 2010 2013 Figure 4.2 Stage of HIV Infection at Diagnosis for Vancouver Coastal Health by Gender, 2010 2013 Figure 4.3 Stage of HIV Infection at Diagnosis for Vancouver Coastal Health by Age Category, 2010 2013 Figure 4.4 Indicator 5 Stage of HIV Infection at Diagnosis for Vancouver Coastal Health by Exposure Category, 2010 2012 HIV Cascade of Care Figure 5.1 Estimated Cascade of Care for Vancouver Coastal Health, 2013 Figure 5.2 Estimated Cascade of Care for Vancouver Coastal Health by Gender, 2013 Figure 5.3 Estimated Cascade of Care for Vancouver Coastal Health by Age Category, 2013 5

Figure 5.4 Estimated Cascade of Care for Vancouver Coastal Health by MSM Status, 2013 Figure 5.5 Estimated Cascade of Care for Vancouver Coastal Health by Age Category and MSM Status, 2013 Figure 5.6 Estimated Cascade of Care for Vancouver Coastal Health by History of IDU, 2013 Figure 5.7 Estimated Cascade of Care for Vancouver Coastal Health by HSDA, 2013 Indicator 6 Table 2 Figure 6.1 Figure 6.2 Indicator 7 Figure 7 Indicator 8 Figure 8 Indicator 9 Table 3 Figure 9 Indicator 10 Figure 10 Indicator 11 Figure 11 Indicator 12 Programmatic Compliance Score (PCS) Probability of Mortality Based on the Programmatic Compliance Score PCS Components for Vancouver Coastal Health, 2012 Q1 2013 Q4 First-Year CD4 Measurement First-Year VL measurement Baseline Resistance Testing Recommended Highly Active Antiretroviral Therapy (HAART) Baseline CD4 200 cells/µl Suppression at 9 Months Historical Trends for PCS Score for Vancouver Coastal Health, 2012 Q1 2013 Q4 New Antiretroviral Therapy Starts in Vancouver Coastal Health BC-CfE Drug Treatment Program Enrollment: New Antiretroviral Participants for Vancouver Coastal Health, 2012 Q1 2013 Q4 CD4 Cell Count at ART Initiation CD4 Cell Count at ART Initiation for Vancouver Coastal Health, 2012 Q1 2013 Q4 Active and Inactive Drug Treatment Program (DTP) Participants Distribution of People on ART in Vancouver Coastal Health, 2013 Q4 Active and Inactive DTP Participants for Vancouver Coastal Health, 2012 Q1 2013 Q4 Antiretroviral Adherence Distribution of Individuals by Adherence Level in 1st Year of Therapy, Based on Pharmacy Refill Compliance for Vancouver Coastal Health, 2012 Q1 2013 Q4 Resistance Testing and Results Cumulative Resistance Testing Results by Resistance Category for Vancouver Coastal Health, 2012 Q1 2013 Q4 AIDS-Defining Illness Figure 12 AIDS Case Rate and Reports for Vancouver Coastal Health, 2006 2013 Indicator 13 HIV-Related Mortality Figure 13 HIV-Related Deaths by Year for Vancouver Coastal Health, 2004 2011 6

Acknowledgements and Contributions British Columbia Centre for Excellence in HIV/AIDS (BC-CfE): The BC-CfE is responsible for the conception, preparation and ongoing review of this quarterly report. The BC-CfE provides the data and outputs for Indicators 5 (HIV Cascade of Care), 6 (Programmatic Compliance Score), 7 (New Antiretroviral Starts), 8 (CD4 Cell Count at ART Initiation), 9 (Active and Inactive Drug Treatment Program Participants), 10 (Antiretroviral Adherence Level), 11 (Resistance Testing Results by Resistance Category), 12 (AIDS-Defining Illness), and 13 (HIV-Related Mortality). The BC-CfE database provides pvl and CD4 cell count testing data, as well as ART use. All pvl measurements in BC are performed at the St Paul s Hospital virology laboratory, thus pvl data capture is 100%. An estimated 80% of all CD4 count measurements performed in the province are captured in the BC-CfE data holdings. The STOP HIV/AIDS Technical Monitoring Committee BC-CFE is responsible for oversight of the monitoring report. Lillian Lourenco writes and compiles the monitoring report. Guillaume Colley, Dr. Viviane Lima and Nada Gataric perform analysis of Indicators 5 13. James Nakagawa is responsible for publishing and editing. This report was conceived and guided by Dr. Julio Montaner. British Columbia Centre for Disease Control (BCCDC): The BCCDC provides the data and outputs for Indicator 1 (HIV Testing Episodes), Indicator 2 (HIV Testing Rate), Indicator 3 (New HIV Diagnoses), Indicator 4 (Stage of HIV at Diagnosis) and Indicator 12 (AIDS-Defining Illness). The BCCDC is the single provincial agency that centralizes all HIV surveillance through the Public Health Microbiology and Reference Laboratory, which does more than 90% of all HIV screening tests in BC and all confirmatory testing. Theodora Consolacion and Dr. Mark Gilbert are responsible for outputs for Indicators 1 4. Other Data Sources: The above databases were supplemented with: (I) The BC Vital Statistics database which was used to calculate Indicator 5. The HIV Cascade of Care and Indicator 13. HIV-Related Mortality. (II) Linkage and preparation of the de-identified individual-level database used for calculating Indicator 5. The HIV Cascade of Care was facilitated by the British Columbia Ministry of Health. (III) The Statistics Canada database: BC and HIV-positive population counts were acquired through the statistics Canada website to calculate HIV-specific mortality rates for Indicator 13. HIV-Related Mortality. 7

Membership of the STOP HIV/AIDS Technical Monitoring Committee BC-CfE Dr. Rolando Barrios, Chair, BC-CfE Kate Heath, BC-CfE Bohdan Nosyk, BC-CfE Viviane Dias Lima, BC-CfE Irene Day, BC-CfE Dr. Mark Gilbert, BCCDC Dr. Mel Kradjen, BCCDC Stephanie Konrad, FHA Joanne Nelson, FNHA Jennifer May-Hadford, IHA James Haggerstone, NHA Dr. Neora Pick, PHSA Dr. Reka Gustafson, VCHA Melanie Rusch, VIHA 8

The Seek and Treat for Optimal Prevention (STOP) HIV/AIDS BC Provincial Program: A Note on Monitoring and Interpreting HIV Indicators The Seek and Treat for Optimal Prevention (STOP) of HIV/AIDS programme is a provincial initiative to improve HIV diagnosis and care delivery in BC through increased HIV-specific funding to all HSDA s across BC. The STOP provincial programme is an expansion of a four-year STOP pilot project which was implemented in two Health Service Delivery Areas in March 2010; the Vancouver HSDA which bears the largest burden of the HIV epidemic in the province and the Northern Interior HSDA which bears a high burden of HIV-related mortality. The STOP pilot project demonstrated the urgent need for improved efforts in early diagnosis of HIV and timely initiation of highly active antiretroviral therapy (HAART) initiation. The expansion to a province-wide programme was announced on November 30th 2013 by the BC Ministry of Health with roll out of funding beginning on April 1st, 2013. This funding is intended to be used in the implementation and evaluation of HIV-related diagnosis and care initiatives within individual HA s. Goals of the project include: 1. A reduction in the number of new HIV infections in BC; 2. Improvements in the quality, effectiveness, and reach of HIV prevention services; 3. An increase in early diagnosis of HIV; 4. A reduction in AIDS cases and HIV-related mortality. The goals of HA-led STOP-funded initiatives are to work toward achieving these goals. To these ends some outcome measures or indicators of progress have been drafted that should be considered in the design and implementation phases of these initiatives. 9

HIV Testing Episodes and Rates In this section, the number of HIV test episodes and point of care (POC) HIV tests conducted each quarter in BC is shown. In general terms the goal is to increase the number of tests performed and to maximize testing efficiency. Test episodes are allocated by region according to where the test is performed. Indicator 1. HIV Testing Episodes Figure 1.1 35 HIV Test Episodes for Vancouver Coastal Health, 2009 Q1 2013 Q4 # HIV Test Episodes (thousands) 30 25 20 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 VCH 18.9 17.9 18.3 17.1 18.8 18.3 18.6 19.3 20.7 20.1 26.0 24.0 27.2 26.9 29.5 29.4 33.5 35.1 33.7 32.7 Figure 1.2 19 HIV Test Episodes by Gender and Prenatal Status for Vancouver Coastal Health, 2009 Q1 2013 Q4 1 # HIV Test Episodes (thousands) 17 15 13 11 9 7 5 3 Female Male Female (Non-prenatal) Female (Prenatal) 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 Female 10.1 9.6 9.8 9.3 10.0 9.7 10.0 9.8 10.6 9.7 10.6 11.6 13.6 13.5 14.7 14.8 17.1 18.0 17.3 16.8 Male 8.4 7.8 8.0 7.4 8.3 8.2 8.2 8.2 8.7 8.0 9.0 9.6 11.3 11.3 12.4 12.6 14.2 15.1 14.0 13.9 Prenatal 3.5 3.2 3.3 3.2 3.4 3.1 3.4 3.5 3.7 3.4 3.5 3.7 4.1 3.7 3.6 3.6 3.6 3.5 3.7 3.7 Non-prenatal 6.6 6.4 6.6 6.1 6.6 6.6 6.6 6.3 6.8 6.4 7.1 8.0 9.5 9.8 11.1 11.2 13.5 14.5 13.6 13.1 Other 0.4 0.5 0.5 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.3 0.2 0.3 0.3 0.2 0.2 0.2 0.1 1 NB: Testing does not include point of care tests. 10

Figure 1.3 10 HIV Test Episodes by Age Category for Vancouver Coastal Health, 2009 Q1 2013 Q4 1,2 9 # HIV Test Episodes (thousands) 8 7 6 5 4 3 2 < 30 30 39 40 49 50 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 < 30 7.0 6.8 7.5 6.8 7.0 6.9 7.2 7.1 7.1 6.8 7.8 8.5 8.9 9.1 9.7 9.5 8.6 9.0 9.2 9.0 30 39 6.4 5.9 6.0 5.7 6.4 6.1 6.2 6.2 6.7 5.9 6.4 6.5 7.8 7.4 7.7 7.6 8.8 9.0 8.9 8.5 40 49 3.2 2.9 2.7 2.6 3.0 2.9 2.8 2.8 3.1 2.8 3.0 3.2 3.9 3.7 3.9 4.1 5.1 5.4 4.9 4.8 50 2.3 2.2 2.2 2.1 2.4 2.4 2.4 2.3 2.8 2.6 3.0 3.4 4.6 4.8 6.0 6.5 9.0 9.9 8.6 8.6 Figure 1.4 # Point-of-Care HIV Tests (thousands) 6 5 4 3 2 1 0 Point-of-Care HIV Tests for Vancouver Coastal Health, 2010 Q4 2013 Q4 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 POC HIV Tests 0.9 1.0 2.0 5.9 2.4 2.1 1.9 2.1 1.7 2.0 1.8 2.1 1.9 2 Data Source: The BC Public Health Microbiology and Reference Laboratory (BCPHMRL) courtesy of the BC Centre for Disease Control (BCCDC). Limitations: 1 Repeat tests in individuals who test using various identifiers may not be identified and these individuals may be counted more than once. 2 POC testing data is available from the fourth quarter of 2010 and onwards. 11

Figure 1.5 30 HIV Test Episodes for Vancouver Coastal Health, 2009 Q1 2013 Q4 28 26 24 22 20 # HIV Test Episodes (thousands) 18 16 14 12 Vancouver 10 8 6 4 2 North Shore / Coast Garibaldi Richmond 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 Richmond 1.2 1.1 1.2 1.1 1.2 1.2 1.2 1.2 1.3 1.2 1.2 1.3 1.5 1.5 1.5 1.6 1.9 2.0 2.0 1.9 Vancouver 15.2 14.5 14.9 13.9 15.3 14.8 15.1 15.7 17.0 16.6 22.4 20.3 22.9 22.9 25.2 25.0 28.5 29.9 28.5 27.3 North Shore / Coast Garibaldi 2.5 2.3 2.3 2.2 2.3 2.3 2.4 2.4 2.4 2.3 2.4 2.4 2.8 2.6 2.7 2.8 3.1 3.3 3.2 3.3 12

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Indicator 2. HIV Testing Rates Figure 2.1 Rate of HIV Testing for Vancouver Coastal Health and HSDAs, 2009 2013 1 HIV Testing Episodes per 100,000 Population 13000 12000 11000 10000 9000 8000 7000 6000 5000 4000 3000 2000 Vancouver Coastal Health 5115.0 5088.8 5338.4 7024.1 8890.4 Richmond 2578.5 2682.5 2773.4 3389.9 3930.4 Vancouver 6614.2 6524.0 6884.2 9361.3 12226.3 North Shore / Coast Garibaldi 3413.6 3430.5 3506.2 4018.5 4451.4 Figure 2.2 10000 Vancouver All VCHA North Shore / Coast Garibaldi Richmond 2009 2010 2011 2012 2013 Rate of HIV Testing by Gender for Vancouver Coastal Health, 2009 2013 1 9000 HIV Testing Episodes per 100,000 Population 8000 7000 6000 5000 4000 Female Male 2009 2010 2011 2012 2013 Female 5412.3 5353.9 5652.4 7515.9 9705.8 Male 4491.8 4527.5 4719.0 6347.5 7949.0 14

Figure 2.3 Rate of HIV Testing by Age Category for Vancouver Coastal Health, 2009 2013 1 17000 16000 15000 14000 13000 12000 HIV Testing Episodes per 100,000 Population 11000 10000 9000 8000 7000 30 39 6000 5000 < 30 40 49 4000 3000 2000 50 1000 2009 2010 2011 2012 2013 < 30 5751.6 5624.5 5918.6 7224.9 7226.0 30 39 10933.2 11200.7 11436.2 13507.3 16236.2 40 49 4870.1 4771.7 4988.9 6561.4 9226.0 50 1820.7 1872.9 2160.4 4134.6 7168.3 15

New HIV Diagnoses Trends in HIV diagnoses by gender and exposure category are described. Interpreting HIV diagnoses must be done with consideration that trends are influenced by both changes in testing rate as well as changes in transmission rates. It is important to note that new HIV diagnoses cases and rates are not synonymous with HIV incidence as a person may have become infected with HIV long before they tested positive for HIV. However, as there is no reliable method for measuring HIV incidence we follow trends in HIV diagnoses. Indicator 3. New HIV Diagnoses Figure 3.1 70 New HIV Diagnoses for Vancouver Coastal Health, 2009 Q1 2013 Q4 3 # HIV Diagnoses 60 50 40 30 Vancouver Coastal Health 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 By Client Residence 51 36 41 36 41 45 41 40 32 48 57 41 43 33 34 32 32 45 40 34 By Provider Address 56 46 45 40 45 50 49 43 34 47 65 42 47 38 38 38 32 49 51 37 Figure 3.2 60 New HIV Diagnoses for Vancouver Coastal Health by Gender, 2009 Q1 2013 Q4 # HIV Diagnoses 50 40 30 20 10 0 Male Female 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 Female 10 4 1 5 8 8 5 3 3 7 2 2 5 4 3 2 4 4 1 2 Male 41 32 40 31 33 37 36 37 29 41 55 39 38 29 31 30 28 41 39 32 3 Data Source: BCCDC 16

Figure 3.3 # HIV Diagnoses 25 20 15 10 5 0 New HIV Diagnoses for Vancouver Coastal Health by Age Category, 2009 Q1 2013 Q4 40 49 30 39 50 < 30 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 < 30 years 9 8 10 9 12 12 12 7 3 10 13 12 11 10 6 13 7 11 14 7 30 39 years 14 11 7 12 16 10 15 12 12 16 22 8 12 11 7 6 13 14 5 6 40 49 years 18 12 18 11 10 16 10 11 11 12 13 13 12 6 11 9 7 8 11 13 50 years 10 5 6 4 3 7 4 10 6 10 9 8 8 6 10 4 5 12 10 8 Figure 3.4 50 New HIV Diagnoses for Vancouver Coastal Health by Exposure Category, 2009 Q1 2013 Q2 4 40 # HIV Diagnoses 30 20 MSM 10 HET 0 Other NIR/Unknown IDU 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 MSM (men having sex with men) 29 25 26 24 30 26 29 27 23 36 43 30 33 25 26 22 20 29 IDU (injection drug use) 8 6 3 3 6 7 5 3 3 2 8 0 3 4 1 3 3 2 HET (heterosexual contact) 12 4 5 8 5 11 7 10 6 10 6 9 7 4 6 6 6 7 Other (other exposure identified) 2 1 2 0 0 1 0 0 0 0 0 2 0 0 0 0 0 0 NIR/Unknown (no identified exposure) 0 0 5 1 0 0 0 0 0 0 0 0 0 0 1 1 3 7 4 BCCDC: Data lags by 6 months. MSM=men who have sex with men; IDU= injection drug user; HET=heterosexual. NIR=No identified risk/exposure. 17

Figure 3.5 70 New HIV Diagnoses for Vancouver Coastal Health by HSDA, 2009 Q1 2013 Q4 60 50 Vancouver # HIV Diagnoses 40 30 20 10 North Shore / Coast Garibaldi 0 Richmond 2009 Q2 Q3 Q4 2010 Q2 Q3 Q4 2011 Q2 Q3 Q4 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 Richmond By Client Residence 3 1 1 1 2 3 3 2 2 0 1 3 0 1 3 0 2 1 0 1 By Provider Address 1 1 3 0 0 2 2 1 1 1 0 2 0 1 2 1 0 0 0 2 Vancouver By Client Residence 45 34 38 34 36 40 34 38 30 46 50 37 41 29 30 31 27 43 36 32 By Provider Address 52 43 41 39 42 46 43 42 33 44 61 40 46 35 34 36 29 47 47 35 North Shore / Coast Garibaldi By Client Residence 3 1 2 1 3 2 4 0 0 2 6 1 2 3 1 1 3 1 4 1 By Provider Address 3 2 1 1 3 2 4 0 0 2 4 0 1 2 2 1 3 2 4 0 By Provider Address is graphed as dashed line in same colour. 18

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Stage of HIV infection at diagnosis Classification of stage of HIV infection, in the absence of information regarding recent testing history, is reliant on clinical information available at the time of diagnosis, including first CD4+ cell count, laboratory results suggestive of acute HIV infection, and clinical presentation with an AIDS-defining illness (Table 1). The benefits of Treatment as Prevention (TasP) are maximized when antiretroviral therapy (ART) is initiated at high CD4 cell counts. Accordingly, it is preferable that individuals newly diagnosed with HIV be in the early stages of HIV infection (stage 0 or 1) to allow for early ART initiation. N.B. Interpretation of stage of HIV infection at diagnosis should proceed with caution. Early increases in diagnosis at late stage (i.e., low CD4 counts) may represent a catching up of previously missed long term infected individuals rather than a trend toward diagnosis at later stage of infection. Figure 4.1 Stage of HIV Infection at Diagnosis for Figure 4.2 Vancouver Coastal Health, 2010 2013 5 100% 80% 60% 40% 2010 2011 2012 2013 Stage 0 1 2a 2b 100% 80% 60% 40% 20% Indicator 4. Stage of HIV Infection at Diagnosis Table 1 Staging Classifications of Infection at Time of HIV Diagnosis Based on CDC HIV Surveillance Case Definitions Stage Criteria Laboratory criteria met for acute HIV infection, or 0 previous negative or indeterminate HIV test within 180 days of first confirmed positive HIV test. 1 CD4 500 2a CD4 350 499 and No AIDS case report 2b Stage 0 CD4 200 349 and 3 not met ( CD4 <200 or AIDS case report ) Unknown No available CD4 and No AIDS case report Stage of HIV Infection at Diagnosis by Gender for Vancouver Coastal Health, 2010 2013 5 Female Male 2010 2011 2012 2013 Stage 0 1 2a 2b 3 2010 2011 2012 2013 0 1 2a 2b 3 20% 0% 3 0% VCH Female Male 2010 2011 2012 2013 2010 2011 2012 2013 2010 2011 2012 2013 Stage 0 38 48 44 34 5 0 6 1 33 48 38 32 Stage 1 39 35 33 32 4 4 3 3 35 31 29 29 Stage 2a 22 33 19 32 3 5 1 3 19 28 18 29 Stage 2b 22 23 18 8 7 4 3 1 15 19 15 7 Stage 3 42 31 34 30 10 4 2 4 32 27 32 26 Unknown 22 17 10 29 0 0 1 3 22 16 9 26 Total (n=) 185 187 158 165 29 17 16 15 156 169 141 149 5 Data Source: BCCDC 20

Figure 4.3 Stage of HIV Infection at Diagnosis by Age Category for Vancouver Coastal Health, 2010 2013 5 < 30 30 39 40 49 50 100% 80% 60% 40% 20% 0% 2010 2011 2012 2013 Stage 0 1 2a 2b 3 2010 2011 2012 2013 2010 2011 2012 2013 2010 2011 2012 2013 0 0 0 1 1 1 2b 2a 3 2a 2a 2b 3 2b 3 Figure 4.4 Stage of HIV Infection at Diagnosis by Exposure Category for Vancouver Coastal Health, 2010 2012 5,6 MSM IDU Heterosexual Other 100% 80% 2010 2011 2012 Stage 0 2010 2011 2012 2010 2011 2012 10 11 12 0 0 2b 2a 1 1 60% 40% 20% 1 2a 2b 3 2a 2b 3 2a 2b 3 3 0% NIR < 30 years 30 39 years 40 49 years 50 years MSM IDU HET Other /Unknown 2010 11 12 13 10 11 12 13 10 11 12 13 10 11 12 13 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 Stage 0 13 9 16 13 15 20 15 11 7 16 7 8 3 3 6 2 30 44 35 3 2 4 5 2 5 0 0 0 0 0 0 Stage 1 9 10 8 13 15 12 13 11 11 6 7 4 4 7 5 4 24 27 26 6 2 1 9 6 6 0 0 0 0 0 0 Stage 2a 4 9 4 7 9 10 3 8 8 10 8 7 1 4 4 10 15 23 14 2 4 4 5 5 1 0 1 0 0 0 0 Stage 2b 3 6 4 0 5 4 4 6 9 9 6 1 5 4 4 1 12 16 13 4 2 2 5 5 3 1 0 0 0 0 0 Stage 3 2 3 5 2 8 7 6 4 11 8 8 12 21 13 15 12 17 15 22 7 1 1 17 13 9 0 2 0 1 0 2 Unknown 8 4 5 4 10 7 2 9 3 2 0 7 1 4 3 9 17 13 8 1 2 0 3 1 1 0 1 0 1 0 1 Total (n=) 39 41 42 39 62 60 43 49 49 51 36 39 35 35 37 38 115 138 118 23 13 12 44 32 25 1 4 0 2 0 3 6 MSM=men who have sex with men; IDU= injection drug user; HET=heterosexual. NIR=No identified risk/exposure. 21

Indicator 5. HIV Cascade of Care The success of seek, test, treat and retain (STTR) strategies like STOP is reliant on early diagnosis of HIV, linking newly diagnosed HIV-positive persons with ongoing care, retaining persons in HIV-care; initiating ART based on best evidenced practices and maintaining optimal ART adherence to ensure a suppressed viral load. These stages of HIV-care can be summarized as: 1. HIV diagnosis, 2. Linkage to HIV care, 3. Retention in HIV care, 4. On ART and 5. Achieving a suppressed VL; collectively, they are referred to as the cascade of care. Leakage between any of these stages of HIV-care means a reduction in the potential of ART as a benefit to the HIV-positive individual and as an HIV transmission prevention method on a population level. Thus, when interpreting trends in the cascade of care, we strive to see increases along each step of the cascade of care (ie. reduced attrition) with the ultimate goal being 100% within each stage of the cascade. Monitoring the Cascade of Care provides a picture as to where deficiencies lie in the delivery and uptake of HIV-care. In this section we present the cascade of care for the year 2012 in BC overall and stratified by sex and age for each Health Authority. Figure 5.1 Estimated Cascade of Care for Vancouver Coastal Health, 2013 7 Figure 5.2 Estimated Cascade of Care for Vancouver Coastal Health by Gender, 2013 8 100% 80% n=4492 4298 3971 3739 3450 Men n=3913 3780 3468 32753058 Women n=579 518 503 464 % of Diagnosed 60% 40% 2891 2591 392 300 % Loss from Previous Stage 20% 0% -20% Linked to Care Retained in Care On Treatment Adherent Suppressed 7,8 Data is for the period 2013 Q1 2013 Q4. Data Sources: 1 British Columbia Centre for Excellence Drug Treatment Program (DTP) Database (ARV use, VL and CD4 count). 2 Administrative data (ex. MSP billings; hospitalization data from the Discharge Abstract Database (DAD)). Limitations: HA assignment is based on the most recent HA of residence of the patient, if not available of the HIV-care provider. If the most recent HA of residence is not updated then the designated HA may be incorrect. NB: Transgender has been assigned to their biological sex. 22

Figure 5.3 Estimated Cascade of Care for Vancouver Coastal Health by Age Category, 2013 9 % of Diagnosed 100% 80% 60% 40% 169 152 <30 n=235 130 110 87 607 548 30-39 n=632 503 450 363 1431 40-49 n=1484 1303 1228 1122 937 >=50 n=2140 2090 1968 1878 1768 1504 20% 0% Linked to Care Retained in Care On Treatment Adherent Suppressed % Loss from Previous Stage -20% 9 Data is for the period 2013 Q1 2013 Q4. Data Sources: 1 British Columbia Centre for Excellence Drug Treatment Program (DTP) Database (ARV use, VL and CD4 count). 2 Administrative data (ex. MSP billings; hospitalization data from the Discharge Abstract Database (DAD)). Limitations: HA assignment is based on the most recent HA of residence of the patient, if not available of the HIV-care provider. If the most recent HA of residence is not updated then the designated HA may be incorrect. 23

Figure 5.4 Estimated Cascade of Care for Vancouver Coastal Health by MSM Status, 2013 10 % of Diagnosed 100% 80% 60% 40% MSM n=1805 1776 1666 1590 1497 1318 Non-MSM n=1170 1147 1131 1053 941 703 1376 Unknown n=1518 1174 1096 1012 870 20% 0% Linked to Care Retained in Care On Treatment Adherent Suppressed % Loss from Previous Stage -20% 10 Data is for the period 2013 Q1 2013 Q4. Data Sources: 1 British Columbia Centre for Excellence Drug Treatment Program (DTP) Database (ARV use, VL and CD4 count). 2 Administrative data (ex. MSP billings; hospitalization data from the Discharge Abstract Database (DAD)). Limitations: HA assignment is based on the most recent HA of residence of the patient, if not available of the HIV-care provider. If the most recent HA of residence is not updated then the designated HA may be incorrect. 24

Figure 5.5 Estimated Cascade of Care for Vancouver Coastal Health by Age Category and MSM Status, 2013 11 100% <30 n=51 30-39 n=190 MSM 40-49 n=565 >=50 n=998 <30 n=39 30-39 n=174 Non-MSM 40-49 n=401 >=50 n=556 80% 60% 40% 20% 11 Data is for the period 2013 Q1 2013 Q4. Data Sources: 1 British Columbia Centre for Excellence Drug Treatment Program (DTP) Database (ARV use, VL and CD4 count). 2 Administrative data (ex. MSP billings; hospitalization data from the Discharge Abstract Database (DAD)). Limitations: HA assignment is based on the most recent HA of residence of the patient, if not available of the HIV-care provider. If the most recent HA of residence is not updated then the designated HA may be incorrect. <30 n=145 30-39 n=268 Unknown 40-49 n=518 >=50 n=587 % Loss from Previous Stage % of Diagnosed 0% -20% -40% 25

Figure 5.6 Estimated Cascade of Care for Vancouver Coastal Health by History of IDU, 2013 12 100% 80% IDU n=1227 12061204 1128 1005 Non-IDU n=2132 2096 1974 1880 1777 996 Unknown n=1133 % of Diagnosed 60% 40% 764 1547 793 731 668 580 20% 0% Linked to Care Retained in Care On Treatment Adherent Suppressed % Loss from Previous Stage -20% 12 Data is for the period 2013 Q1 2013 Q4. Data Sources: 1 British Columbia Centre for Excellence Drug Treatment Program (DTP) Database (ARV use, VL and CD4 count). 2 Administrative data (ex. MSP billings; hospitalization data from the Discharge Abstract Database (DAD)). Limitations: HA assignment is based on the most recent HA of residence of the patient, if not available of the HIV-care provider. If the most recent HA of residence is not updated then the designated HA may be incorrect. 26

Figure 5.7 Estimated Cascade of Care for Vancouver Coastal Health by HSDA, 2013 13 100% 80% North Shore/Coast Garibaldi n=276 259 245 234 216 116 110 Richmond n=129 102 96 3922 Vancouver n=4085 3616 3403 3138 % of Diagnosed 60% 40% 186 88 2617 % Loss from Previous Stage 20% 0% -20% Linked to Care Retained in Care On Treatment Adherent Suppressed 13 Data is for the period 2013 Q1 2013 Q4. Data Sources: 1 British Columbia Centre for Excellence Drug Treatment Program (DTP) Database (ARV use, VL and CD4 count). 2 Administrative data (ex. MSP billings; hospitalization data from the Discharge Abstract Database (DAD)). Limitations: HA assignment is based on the most recent HA of residence of the patient, if not available of the HIV-care provider. If the most recent HA of residence is not updated then the designated HA may be incorrect. 27

Indicator 6. The Programmatic Compliance Score (PCS) The Programmatic Compliance Score (PCS) is a summary measure of risk of future death, immunologic failure and virologic failure from all causes for people who are starting ART for the first time. It is composed of patient- and physician-driven effects. PCS scores range from 0 6 with higher scores indicative of poorer health outcomes and greater risk of death. Table 1 provides mortality, immunologic failure and virologic failure probabilities for given PCS scores. We interpret an individual with a PCS 4 as being 22 times more likely to die, almost 10 times more likely to have immunologic failure and nearly 4 times as likely to demonstrate virologic failure compared to those individuals with a PCS score of 0. A detailed description of how the PCS score is calculated and its valida tion can be found in the technical report. In short, PCS scores are calculated by summing the results (yes=1, no=0) of six un-weighted nonperformance indicators based on IAS USA treatment guidelines: 1. having <3 CD4 cell count tests in the first year after starting antiretroviral therapy (ART); 2. having <3 plasma viral load (VL) tests in the first year after starting ART; 3. not having drug resistance testing done prior to starting ART; 4. starting on a non-recommended ART regimen; 5. starting therapy with CD4<200 cells/µl; and 6. not achieving viral suppression within 9 months since ART initiation. In this section we provide PCS scores and their components over time for the province of BC. A decline to 0%, (i.e., all individuals having a score of 0) is the eventual goal. Table 2. The Probability of Mortality, Immunologic Failure and Virologic Failure based on the Programmatic Compliance Score Programmatic Compliance Score Mortality Risk Ratio (95% Confidence Interval) Immunologic Failure Risk Ratio (95% CI) 0 (Best score) 1 ( ) 1 ( ) 1 ( ) Virologic Failure Risk Ratio (95% CI) 1 3.81 (1.73 8.42) 1.39 (1.04 1.85) 1.32 (1.05 1.67) 2 7.97 (3.70 17.18) 2.17 (1.54 3.04) 1.86 (1.46 2.38) 3 11.51 (5.28 25.08) 2.93 (1.89 4.54) 2.98 (2.16 4.11) 4 or more (Worst score) 22.37 (10.46 47.84) 9.71 (5.72 16.47) 3.80 (2.52 5.73) Reference: Lima VD, Le A, Nosyk B, Barrios R, Yip B, et al. (2012) Development and Validation of a Composite Programmatic Assessment Tool for HIV Therapy. PLoS ONE 7(11): e47859. doi:10.1371/journal.pone.0047859 28

Figure 6.1 30% PCS Components for Vancouver Coastal Health, 2011 2013 14 20% Baseline CD4 < 200 cells/µl Non Viral Suppression at 9 Mo. 10% 0% Non-Recommended ART < 3 CD4 Tests No Baseline Genotype < 3 Viral Load Tests 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 n= 209 213 228 242 241 226 204 187 Figure 6.2 100% 0 Historical Trends for PCS Score for Vancouver Coastal Health, 2011 Q1 2013 Q4 15 80% Distribution of PCS Score 60% 40% 20% 0% 1 2 3 4 n= Q1 2012 209 Q2 213 Q3 228 Q4 242 Q1 2013 241 Q2 226 Q3 204 Q4 187 Improving Health Outcomes NB: A score of 0 is the best score and a score of 4 or more is the worst score. 14 Data Source: British Columbia Centre for Excellence Drug Treatment Program (DTP) Database. Limitations: CD4 cell count capture is approximately 80%. 15 Data Source: British Columbia Centre for Excellence Drug Treatment Program (DTP) Database. Each quarter s data is calculated as the sum of the 4 quarters leading up to it. e.g. 2012 Q1 is calculated from 2011 Q2 2012 Q1. 29

Antiretroviral Uptake In this section we present trends in ART uptake, the number and proportion of new HIV treatment initiations and the number of active and inactive DTP participants. Trends in ART uptake should be interpreted under the consideration of changing BC HIV treatment guidelines. BC HIV treatment guidelines are updated regularly by the BC-CfE Therapeutic Guidelines Committee and reflect those of the International AIDS Society. Most recent changes were made in 2012 and HIV treatment is now recommended for all HIV-positive adults regardless of CD4 cell count; as evidence demonstrates that early initiation of HIV treatment maximizes both the individual s health outcomes as well as the potential of ART as a form of HIV transmission prevention at a population level. As such, trends in the number and proportion of persons on ART and new ART starts (in both naïve and experienced persons) are expected to increase over time at higher CD4 cell counts. Indicator 7. New Antiretroviral Therapy Starts in Vancouver Coastal Health Figure 7 # Participants 90 80 70 60 50 40 30 20 Indicator 8. CD4 Cell Count at ART Initiation Figure 8 100% BC-CfE Drug Treatment Program Enrollment: New ART Participants in Vancouver Coastal Health, 2012 Q1 2013 Q4 16 2012 First Starts Experienced Starts Q2 Q3 Q4 2013 CD4 Cell Count at ART Initiation of ART-Naïve DTP Participants in Vancouver Coastal Health, 2012 Q1 2013 Q4 17 500 cells/µl Q2 Q3 Q4 700 % in CD4 Cell Count Category at ART Initiation 80% 60% 40% 20% 350 499 200 349 50 199 Median 600 500 400 300 200 Median CD4 Cell Count at ART Initiation (cells/µl) 0% n= < 50 cells/µl Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2012 2013 79 55 53 52 46 51 57 33 100 16 Data Source: Drug Treatment Program Database Limitation: DTP participants are designated to an HA based on most current residence provided by the participant. 17 Data Source: Drug Treatment Program Database Limitations: CD4 cell count data is approximately 80% complete. 30

Indicator 9. Active and Inactive DTP Participants Table 3. Distribution of People on ART for Vancouver Coastal Health, 2013 Q4 16 Age < 30 132 30 39 523 40 49 1242 50 1884 Gender Male 3321 Female 460 Exposure MSM 1589 IDU 1116 Total 3781 Figure 9 3900 Active and Inactive DTP Participants in Vancouver Coastal Health, 2012 Q1 2013 Q4 19 3800 3700 Active # Participants 3600 3500 700 600 Inactive 500 2012 Q2 Q3 Q4 2013 Q2 Q3 Q4 18 Data Source: Drug Treatment Program Database Limitation: DTP participants are designated to an HA based on most current residence provided by the participant. Definitions: On antiretroviral therapy defined as being on treatment in the current quarter Unknown/not stated defined as being on treatment in the current quarter, and city of residence unknown 19 Active DTP participants: are those who are prescribed one or more drugs in the last six months. Inactive DTP Participants: Persons no longer prescribed drugs through the HIV/AIDS Drug Treatment Program in the last quarter. 31

Antiretroviral Adherence Level In this section we present trends in prescription refill adherence levels for individuals in their first year of treatment. Given that the benefits of ART are compromised in the presence of imperfect ART adherence, we expect to see the proportion of persons on ART achieving near perfect adherence (ie. 95%) to increase with time. Furthermore, it is important that trends in the proportion of ART users achieving prescription refill adherence of 95% keep pace with new ART starts and increase among those continuing on ART. Indicator 10. Antiretroviral Adherence Figure 10 100% Distribution of Individuals by Adherence Level in 1st Year of Therapy, Based on Pharmacy Refill Compliance for Vancouver Coastal Health, 2012 Q1 2013 Q4 20 95% 80% % Achieving Prescription Refill Adherence 60% 40% 20% 80 to < 95% 0% n= 40 to < 80% < 40% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2012 2013 88 75 75 67 76 59 51 51 20 Data Source: Drug Treatment Program Database Limitation: Prescription refill adherence is used as a proxy for patient adherence. 32

Indicator 11. Resistance Testing and Results In this section, we present trends in cumulative resistance testing by resistance category: Suppressed (where a DTP participant s viral load is too low to be genotyped); Wild Type (where no HIV treatment resistances were discovered), Never Genotyped, and Resistances to one, two or three HIV treatment classes. Resistance testing prior to ART initiation is recommended in the BC HIV treatment primary care guidelines. Thus, it is expected that trends over time should find all persons enrolled in the DTP to have been genotyped. Trends over time should also show an increase in the proportion of DTP participants achieving a suppressed status and an increase in resistance testing should not lead to an increase in the number of ART resistances occurring. 100% Figure 11 Suppressed Cumulative Resistance Testing Results by Resistance Category for Vancouver Coastal Health, 2012 Q1 2013 Q4 21 80% % DTP Patients 60% 40% 20% Wild Type 0% Never Genotyped 1-Class 2-Class 3-Class n= Q1 2012 3332 Q2 3234 Q3 3259 Q4 3185 Q1 2013 3314 Q2 3269 Q3 3261 Q4 3141 21 Data Source: Drug Treatment Program Database Limitation: DTP participants are designated to an HA based on most current residence provided by the participant. 33

Indicator 12. AIDS-Defining Illness Improvements in ART and the expansion of ART province-wide has led to very low numbers of recorded AIDS cases across BC. However, interpreting trends in AIDS cases is challenging as AIDS reporting is passive in BC and it is likely that they are under reported across all Health Authorities. In addition to under reporting, methods of reporting AIDS cases are inconsistent across HA s and do not truly reflect the current reality of new AIDS diagnoses. Efforts will need to be made to improve under and inconsistent reporting of AIDS cases across all HA s. The table below shows AIDS cases using three definitions. First, AIDS cases were defined as the number of physicianreported AIDS defining illness (ADI) in a given year. AIDS case reporting is a passive process; as such, we have plotted DTP reported AIDS cases as well as the proportion of persons initiating ART with a CD4<200 cells/µl. Figure 12 15 AIDS Case Rate and Reports for Vancouver Coastal Health, 2006 2013 22 CD4<200 at ART Initiation Rate per 100,000 population 10 5 AIDS: BCCDC Reports AIDS: DTP Reports 0 CD4<200 at ART initiation AIDS: DTP Reports AIDS: BCCDC Reports 2006 2007 2008 2009 2010 2011 2012 2013 CASES 119 128 95 82 69 52 47 42 PER 100K 11.2 11.8 8.7 7.4 6.1 4.5 4 3.5 CASES 62 58 61 42 36 23 17 5 PER 100K 5.8 5.4 5.6 3.8 3.2 2 1.4 0.3 CASES 54 63 67 46 35 30 16 PER 100K 5.1 5.8 6.1 4.1 3.1 2.6 1.4 22 Data Source: Drug Treatment Program Database Limitation: AIDS case reporting was investigated using 2 definitions: First, using AIDS cases reported in AIDS case report forms from the DTP, and second, using a CD4 cell count of <200 cells/µl at time of ART initiation using DTP data. AIDS case reporting is passive in BC, thus; AIDS case reporting is not well captured. The DTP sends out AIDS reporting forms to physicians annually. Interpreting AIDS case reports should be done with these limitations in mind. AIDS data is updated annually as very few AIDS cases reports are reported in general and trends would be difficult to notice if reported quarterly. 34

Indicator 13. HIV-Related Mortality Evidence indicates that individuals who initiate treatment with recommended ART in a timely fashion may live near normal lifespans. Excess mortality among HIV positive persons is, therefore, an important measure of HIV care with a goal of minimizing HIVrelated mortality in British Columbia. Figure 13 Rate per 100 HIV+ Population 1.5 1.0 0.5 0.0 HIV-Related Deaths by Year for Vancouver Coastal Health, 2004 2011 23 Rate per 100,000 Population 8 7 6 5 4 3 2 1 2004 2005 2006 2007 2008 2009 2010 2011 HIV-Related Deaths 55 88 73 49 36 34 18 20 Per 100 HIV+ Population 0.90 1.41 1.15 0.76 0.54 0.50 0.26 0.28 Per 100,000 Population 5.30 8.46 6.79 4.51 3.30 3.05 1.58 1.73 23 Data Source: BC Vital Statistics Limitation: 1. DTP participants are designated to an HA based on most current residence provided by the participant. 2. Mortality data is updated annually. 3. The most recent available data was used. 35

Appendices Indicator 1: Test Episodes (thousands) 2009 2010 2011 2012 2013 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Vancouver Coastal Health 18.9 17.9 18.3 17.1 18.8 18.3 18.6 19.3 20.7 20.1 26.0 24.0 27.2 26.9 29.5 29.4 33.5 35.1 33.7 32.7 Gender Female 10.1 9.6 9.8 9.3 10.0 9.7 10.0 9.8 10.6 9.7 10.6 11.6 13.6 13.5 14.7 14.8 17.1 18.0 17.3 16.8 Male 8.4 7.8 8.0 7.4 8.3 8.2 8.2 8.2 8.7 8.0 9.0 9.6 11.3 11.3 12.4 12.6 14.2 15.1 14.0 13.9 Other 0.4 0.5 0.5 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.3 0.2 0.3 0.3 0.2 0.2 0.2 0.1 Female (Prenatal) 3.5 3.2 3.3 3.2 3.4 3.1 3.4 3.5 3.7 3.4 3.5 3.7 4.1 3.7 3.6 3.6 3.6 3.5 3.7 3.7 Female (Non-prenatal) 6.6 6.4 6.6 6.1 6.6 6.6 6.6 6.3 6.8 6.4 7.1 8.0 9.5 9.8 11.1 11.2 13.5 14.5 13.6 13.1 Age < 30 7.0 6.8 7.5 6.8 7.0 6.9 7.2 7.1 7.1 6.8 7.8 8.5 8.9 9.1 9.7 9.5 8.6 9.0 9.2 9.0 30 39 6.4 5.9 6.0 5.7 6.4 6.1 6.2 6.2 6.7 5.9 6.4 6.5 7.8 7.4 7.7 7.6 8.8 9.0 8.9 8.5 40 49 3.2 2.9 2.7 2.6 3.0 2.9 2.8 2.8 3.1 2.8 3.0 3.2 3.9 3.7 3.9 4.1 5.1 5.4 4.9 4.8 50 2.3 2.2 2.2 2.1 2.4 2.4 2.4 2.3 2.8 2.6 3.0 3.4 4.6 4.8 6.0 6.5 9.0 9.9 8.6 8.6 POC HIV Tests 0.9 1.0 2.0 5.9 2.4 2.1 1.9 2.1 1.7 2.0 1.8 2.1 1.9 Richmond 1.2 1.1 1.2 1.1 1.2 1.2 1.2 1.2 1.3 1.2 1.2 1.3 1.5 1.5 1.5 1.6 1.9 2.0 2.0 1.9 Vancouver 15.2 14.5 14.9 13.9 15.3 14.8 15.1 15.7 17.0 16.6 22.4 20.3 22.9 22.9 25.2 25.0 28.5 29.9 28.5 27.3 North Shore / Coast Garibaldi 2.5 2.3 2.3 2.2 2.3 2.3 2.4 2.4 2.4 2.3 2.4 2.4 2.8 2.6 2.7 2.8 3.1 3.3 3.2 3.3 Indicator 2: Rate of HIV Testing per 100,000 2009 2010 2011 2012 2013 Vancouver Coastal Health 5115.0 5088.8 5338.4 7024.1 8890.4 Richmond 2578.5 2682.5 2773.4 3389.9 3930.4 Vancouver 6614.2 6524.0 6884.2 9361.3 12226.3 North Shore / Coast Garibaldi 3413.6 3430.5 3506.2 4018.5 4451.4 Gender Female 5412.3 5353.9 5652.4 7515.9 9705.8 Male 4491.8 4527.5 4719.0 6347.5 7949.0 Age < 30 5751.6 5624.5 5918.6 7224.9 7226.0 30 39 10933.2 11200.7 11436.2 13507.3 16236.2 40 49 4870.1 4771.7 4988.9 6561.4 9226.0 50 1820.7 1872.9 2160.4 4134.6 7168.3 2009 2010 2011 2012 2013 Indicator 3: New HIV Diagnoses Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Vancouver Coastal By Client Residence 51 36 41 36 41 45 41 40 32 48 57 41 43 33 34 32 32 45 40 34 Health By Provider Address 56 46 45 40 45 50 49 43 34 47 65 42 47 38 38 38 32 49 51 37 Gender Female 10 4 1 5 8 8 5 3 3 7 2 2 5 4 3 2 4 4 1 2 Male 41 32 40 31 33 37 36 37 29 41 55 39 38 29 31 30 28 41 39 32 Age < 30 9 8 10 9 12 12 12 7 3 10 13 12 11 10 6 13 7 11 14 7 30 39 14 11 7 12 16 10 15 12 12 16 22 8 12 11 7 6 13 14 5 6 40 49 18 12 18 11 10 16 10 11 11 12 13 13 12 6 11 9 7 8 11 13 50 10 5 6 4 3 7 4 10 6 10 9 8 8 6 10 4 5 12 10 8 Exposure MSM 29 25 26 24 30 26 29 27 23 36 43 30 33 25 26 22 20 29 IDU 8 6 3 3 6 7 5 3 3 2 8 0 3 4 1 3 3 2 HET 12 4 5 8 5 11 7 10 6 10 6 9 7 4 6 6 6 7 Other 2 1 2 0 0 1 0 0 0 0 0 2 0 0 0 0 0 0 NIR/Unknown 0 0 5 1 0 0 0 0 0 0 0 0 0 0 1 1 3 7 Richmond By Client Residence 3 1 1 1 2 3 3 2 2 0 1 3 0 1 3 0 2 1 0 1 By Provider Address 1 1 3 0 0 2 2 1 1 1 0 2 0 1 2 1 0 0 0 2 Vancouver By Client Residence 45 34 38 34 36 40 34 38 30 46 50 37 41 29 30 31 27 43 36 32 By Provider Address 52 43 41 39 42 46 43 42 33 44 61 40 46 35 34 36 29 47 47 35 North Shore By Client Residence 3 1 2 1 3 2 4 0 0 2 6 1 2 3 1 1 3 1 4 1 / Coast Garibaldi By Provider Address 3 2 1 1 3 2 4 0 0 2 4 0 1 2 2 1 3 2 4 0 36

Indicator 4: Stage of HIV Infection at Baseline VCH Female Male < 30 years 30 39 years 40 49 years 10 11 12 13 10 11 12 13 10 11 12 13 10 11 12 13 10 11 12 13 10 11 12 13 Stage 0 38 48 44 34 5 0 6 1 33 48 38 32 13 9 16 13 15 20 15 11 7 16 7 8 Stage 1 39 35 33 32 4 4 3 3 35 31 29 29 9 10 8 13 15 12 13 11 11 6 7 4 Stage 2a 22 33 19 32 3 5 1 3 19 28 18 29 4 9 4 7 9 10 3 8 8 10 8 7 Stage 2b 22 23 18 8 7 4 3 1 15 19 15 7 3 6 4 0 5 4 4 6 9 9 6 1 Stage 3 42 31 34 30 10 4 2 4 32 27 32 26 2 3 5 2 8 7 6 4 11 8 8 12 Unknown 22 17 10 29 0 0 1 3 22 16 9 26 8 4 5 4 10 7 2 9 3 2 0 7 Total 185 187 158 165 29 17 16 15 156 169 141 149 39 41 42 39 62 60 43 49 49 51 36 39 50 years MSM IDU Heterosexual Other Exposure NIR/Unknown 10 11 12 13 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 Stage 0 3 3 6 2 30 44 35 3 2 4 5 2 5 0 0 0 0 0 0 Stage 1 4 7 5 4 24 27 26 6 2 1 9 6 6 0 0 0 0 0 0 Stage 2a 1 4 4 10 15 23 14 2 4 4 5 5 1 0 1 0 0 0 0 Stage 2b 5 4 4 1 12 16 13 4 2 2 5 5 3 1 0 0 0 0 0 Stage 3 21 13 15 12 17 15 22 7 1 1 17 13 9 0 2 0 1 0 2 Unknown 1 4 3 9 17 13 8 1 2 0 3 1 1 0 1 0 1 0 1 Total 35 35 37 38 115 138 118 23 13 12 44 32 25 1 4 0 2 0 3 Indicator 5: HIV Cascade of Care Diagnosed Linked Retained On ART Adherent Suppressed Vancouver Coastal Health 4492 4298 3971 3739 3450 2891 Age Category < 30 235 169 152 130 110 87 Age Category and MSM Status 30 39 632 607 548 503 450 363 40 49 1484 1431 1303 1228 1122 937 50 2140 2090 1968 1878 1768 1504 MSM < 30 51 48 40 34 31 28 30 39 190 185 167 151 138 114 40 49 565 557 515 494 461 405 50 998 986 944 911 867 771 Non-MSM < 30 39 39 37 34 28 18 30 39 174 169 155 141 121 87 40 49 401 392 389 359 313 228 50 556 547 547 519 479 370 Unknown < 30 145 83 76 62 51 41 30 39 268 253 226 211 191 162 40 49 518 482 399 375 348 304 50 587 558 474 448 422 363 Gender Male 3913 3780 3468 3275 3058 2591 Injection Drug Use Female 579 518 503 464 392 300 IDU 1227 1206 1204 1128 1005 764 Non-IDU 2132 2096 1974 1880 1777 1547 Unknown 1133 996 793 731 668 580 MSM Status MSM 1805 1776 1666 1590 1497 1318 Health Authority Non-MSM 1170 1147 1131 1053 941 703 Unknown 1518 1376 1174 1096 1012 870 Richmond 129 116 110 102 96 88 Vancouver 4085 3922 3616 3403 3138 2617 North Shore / Coast Garibaldi 276 259 245 234 216 186 37

Indicator 6: Programmatic Compliance Score (PCS) 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 < 3 CD4 Tests 4.8% 4.7% 4.4% 5.8% 4.1% 4.9% 5.9% 5.9% < 3 Viral Load Tests 6.2% 5.6% 5.3% 5.4% 3.3% 3.1% 3.4% 3.2% No Baseline Genotype 4.3% 5.2% 6.1% 5.0% 5.0% 4.9% 3.9% 4.3% Baseline CD4 < 200 cells/µl 23.4% 23.9% 20.6% 19.0% 18.7% 19.5% 23.5% 23.0% Non-Recommended ART 2.9% 2.3% 2.6% 2.1% 1.2% 1.8% 5.4% 9.6% Non Viral suppression at 9 Mo. 19.1% 18.8% 21.9% 24.4% 22.8% 23.9% 23.0% 21.9% PCS Score: 0 123 124 132 141 148 139 115 99 PCS Score: 1 57 60 65 64 60 50 51 57 PCS Score: 2 20 20 21 27 26 30 32 26 PCS Score: 3 6 7 8 9 7 7 6 3 PCS Score: 4 or more 3 2 2 1 0 0 0 2 Total (n=) 209 213 228 242 241 226 204 187 Indicator 7: New DTP ARV Participants First Starts 79 55 53 54 46 51 57 33 Experienced Starts 39 50 41 59 46 45 57 74 Indicator 8: CD4 Cell Count at ART Initiation for ARV-Naïve DTP Participants CD4 500 22 23 14 21 7 19 16 14 CD4 350 499 28 11 17 12 14 11 15 9 CD4 200 349 17 11 10 9 13 8 14 6 CD4 50 199 8 6 10 6 9 10 12 4 CD4 < 50 4 4 2 4 3 3 0 0 CD4 Median (cells/µl) 380 420 370 450 320 400 380 470 Total (n=) 79 55 53 52 46 51 57 33 Indicator 9: Active and Inactive DTP Participants Active DTP Participants 3637 3644 3666 3690 3704 3715 3737 3781 Inactive DTP Participants 606 603 611 617 629 630 645 642 Indicator 10: Antiretroviral Adherence 95% 70 57 55 48 59 50 35 40 80% to < 95% 14 12 15 12 10 8 12 6 40% to < 80% 3 6 3 7 5 1 4 5 < 40% 1 0 2 0 2 0 0 0 Total (n=) 88 75 75 67 76 59 51 51 Indicator 11: Resistance Testing and Results Suppressed 2545 2512 2549 2464 2619 2600 2663 2576 Wild Type 584 543 532 528 514 493 443 442 Never Genotyped 57 49 42 47 42 39 35 22 1-Class 129 106 104 114 108 103 94 84 2-Class 15 23 27 28 26 31 19 14 3-Class 2 1 5 4 5 3 7 3 Total (n=) 3332 3234 3259 3185 3314 3269 3261 3141 Indicator 12: AIDS-Defining Illness 2006 2007 2008 2009 2010 2011 2012 2013 CD4 < 200 at Cases 119 128 95 82 69 52 47 42 ART initiation Rate per 100,000 11.2 11.8 8.7 7.4 6.1 4.5 4.0 3.5 AIDS Cases Cases 62 58 61 42 36 23 17 5 (DTP Reports) Rate per 100,000 5.8 5.4 5.6 3.8 3.2 2.0 1.4 0.3 AIDS Cases Cases 54 63 67 46 35 30 16 (BCCDC Reports) Rate per 100,000 5.1 5.8 6.1 4.1 3.1 2.6 1.4 Indicator 13: HIV-Related Mortality 2004 2005 2006 2007 2008 2009 2010 2011 Vancouver Coastal Health 55 88 73 49 36 34 18 20 Per 100 HIV+ Population 0.90 1.41 1.15 0.76 0.54 0.50 0.26 0.28 Per 100,000 Population 5.30 8.46 6.79 4.51 3.30 3.05 1.58 1.73 38